title: Biofeedback therapy for faecal incontinence: a rural and regional perspective.
abstract: BACKGROUND
  Faecal incontinence is the involuntary loss of liquid or solid stool with or without the patient's awareness. It affects 8-11% of Australian community dwelling adults and up to 72% of nursing home residents with symptoms causing embarrassment, loss of self-respect and possible withdrawal from normal daily activities. Biofeedback, a technique used to increase patient awareness of physiological processes not normally considered to be under voluntary control, is a safe, conservative first-line therapy that has been shown to reduce symptom severity and improve patient quality of life. The Townsville Hospital, a publicly funded regional hospital with a large rural catchment area, offers anorectal biofeedback for patients with faecal incontinence, constipation and chronic pelvic pain. The aim of this report is to describe the effect of the biofeedback treatment on the wellbeing of regional and rural participants in a study of biofeedback treatment for faecal incontinence in the Townsville Hospital clinic.
  
  
  METHODS
  There were 53 regional (14 male) and 19 rural (5 male) participants (mean age 62.1 years) enrolled in a biofeedback study between January 2005 and October 2006. The program included 4 sessions one week apart, 4 weeks home practice of techniques learnt and a final follow-up reassessment session. Session one included documenting relevant history, diet, fibre, and fluid intake and treatment goals; anorectal function and proctometrographic measurements were assessed. Patients were taught relaxation (diaphragmatic) breathing in session two with a rectal probe and the balloon inserted, prior to inflating the balloon to sensory threshold. In session three, patients were taught anal sphincter and pelvic floor exercises linking the changes in anal pressures seen on the computer monitor with the exercises performed and sensations felt. Session four included improving anal and pelvic floor exercises, learning a defecation technique and receiving instructions for 4 weeks home practice. At the fifth session, home practice and bowel charts were reviewed and anorectal function was reassessed. Symptom severity and quality of life were assessed by surveying participants prior to sessions one and two and following session five. Patients were interviewed after session five to determine their satisfaction with the therapy and the helpfulness of individual program components. They were mailed a follow-up survey 2 years later.
  
  
  RESULTS
  Regional participants lived within 30 min drive of the clinic (median distance 8 km) while rural participants travelled up to 903 km (median 339 km, p<0.001) to attend the clinic. Faecal Incontinence risk factors were similar for rural and regional participants. Rural participants reported poorer general health (p=0.004) and their symptoms affected their lifestyle more negatively (p=0.028). Participants' incontinence (p<0.001) and quality of life (p<0.001) improved significantly over the treatment period. Improvement for rural participants over the course of treatment was marginally better than that of regional participants, although not significantly. More than 97% of patients reported that the biofeedback program was very/extremely helpful and all participants attending the final session reported that they would advise a friend in a similar situation not to wait, but seek help immediately, with more than half specifically citing the biofeedback program. Two years later regional participants' symptoms and quality of life continued to improve while rural participants' quality of life had regressed to pre-treatment levels.
  
  
  CONCLUSIONS
  For equivalent long term improvement in faecal continence and quality of life to be achieved in both regional and rural participants, an additional follow-up session with the biofeedback therapist, ongoing local support provided by continence advisors, or both, should be investigated for rural patients.
authors.affiliation: James Cook University, Townsville, Queensland, Australia.
authors.forename: L M
authors.initials: LM
authors.lastname: Bartlett
authors.forename: K
authors.initials: K
authors.lastname: Sloots
authors.forename: M
authors.initials: M
authors.lastname: Nowak
authors.forename: Y H
authors.initials: YH
authors.lastname: Ho
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001315:Australia; D001364:Awareness / Q000502:physiology; D001676:Biofeedback, Psychology; D005242:Fecal Incontinence / Q000451:nursing / Q000628:therapy*; D005260:Female; D005500:Follow-Up Studies; D018939:Holistic Nursing; D006779:Hospitals, Public; D006801:Humans; D007407:Interviews as Topic; D008297:Male; D008875:Middle Aged; D017060:Patient Satisfaction; D011788:Quality of Life; D012424:Rural Population